DS9 Document EFTA00313333

S A Credit Card Authorization Form THE PENINSULA This form has been created in order to allow you to have third party expenses charged to your credit card. Please provide all the information r uested below to ensure prompt processing. We ask that you either fax this completed form to The Peninsula Spa at or e-mail it to Third Party Payment of Services ONLY Guest Name: Date of Services: Rate Information and Approved Charges Services: Rate: K Service ONLY K Service and 4.5% Sales Tax ONLY 2*-Service, 4.5% Sales Tax and Gratuity j:(3 Additional Services Rendered (i.e. Treatment Upgrades) a Products Purchased Maximum Allowable Amount: JO, c, c r ei Please Keep My Form on File For Future Use ET Cardholder Infarosalion Name as it appears on the credit card: Type of Card: K Visa K Mastercard Account Type: 2 Individual (Personal Credit Card) K Corporate Company Name: Credit Card Number: ■ Address (Billing Address): City, State and Zip: r 01 Phone Number: I C 7/ U7 American Express K Discover Fax or Alternate Number: Expiration Date: I certify that all information is complete and accurate. I hereby authorize The Patinsula Spa, New York to collect payment for all charges as indicated on this form by processing a charge to the credit card listed above. I certify that I am the authorized signer of the credit card listed above. Please mile 1hal Ise ;vellum a haAtrium signalmv to order to process this order. Cardholder Name (Please print) Cardholder Signature: Date: EFTA00313333